Press Release

Embargoed Until Contact

September 13, 2012

Sue Ducat
Director of Communications
(301) 841-9962


Improving Care Transitions


Bethesda, MD -- A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation looks at efforts to improve care transitions. These are the movements that patients make among health care providers and settings as their needs change during the course of illness--for example, from a hospital to a nursing home, and sometimes back again. If these transitions aren't carefully coordinated, they can result in harm to patients and waste money. Researchers estimated that in 2011, poor transitions caused between $25 and $45 billion in wasteful medical spending through avoidable complications and unnecessary hospital readmissions.


Topics covered in the brief include:


  • The causes of poor care transitions. One major factor is the lack of communication between the hospital and the patient's regular outpatient provider. For example, often a hospital will not forward a patient's records back to a primary care physician, so the doctor won't know that the patient needs follow-up care. And patients frequently don't understand discharge plans--such as medication instructions--given to them at the hospital.

  • Improving care transitions. The policy brief describes several models for improving care transitions, including the introduction of patient coaches to help patients manage medications, schedule appointments, and respond to medical "red flags," including fever or shortness of breath. The Affordable Care Act also contains a number of relevant provisions. For example, hospitals can receive increases to their Medicare payments if they meet or exceed performance targets for quality measures, such as asking patients if they have the help they need at home. And the quality metrics that must be met by accountable care organizations to benefit financially under the Medicare Shared Savings Program include six that pertain to care coordination, including preventing unnecessary hospital readmissions.

  • Other policy options. If such measures don't succeed in improving care transitions, the Centers for Medicare and Medicaid Services' statutory authority provides additional options, including using a newly created billing code that would enable physicians to bill for delivery of care transition services. Other policy options include adding a care transitions measure to Medicare's Hospital Inpatient Quality Reporting Program and further limiting payments for certain hospital readmissions.
About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically and health policy briefs published twice monthly at Read daily perspectives on Health Affairs Blog. Download weekly Narrative Matters podcasts on iTunes.